Jessica is a 38 year old woman who started having pain with intercourse (dyspareunia) with her husband after recurrent urinary tract infections (UTIs) and yeast infections over a period of 8 months. She also had yeast infections around the same time. She was treated with antibiotics and antifungal medications. At first, the pain with intercourse was just mild, but the pain started increasing over time until she could no longer tolerate intercourse at all. Even after she had repeated tests showing that she was no longer was having UTIs or yeast infections, she was still having pain with attempts at intercourse. She then became fearful of intercourse due to the pain association. She also noticed it took longer to urinate and she sometimes felt like she had to “push” to get the urine flow to start. Highlights of Clinical Findings: Jessica had an anxiety level of 7/10 with regard to fear of pain with GYN exam or attempts at vulvar touch or intercourse. The most significant findings: 1. Tightness and tenderness of the levator ani pelvic floor muscles 2. During a pelvic floor muscle examination, Jessica would reflexively tighten her inner thighs and her pelvic floor muscles would contract and go into spasm(a vaginismus response), making it harder to perform the exam. The biofeedback surface emg testing showed a slightly elevated resting baseline of 3.8 mv.

Treatment: The first part of treatment focused on decreasing anxiety levels associated with the thought of touch or direct touch near the vagina. This involved pelvic physical therapist guided exercises with guided imagery and then a patient home program for guided imagery, graded imagery and meditation. Instruction on use of graduated dilators for home was implemented. Check out this guide to using dilators. Manual therapy was implemented to work on desensitization strategies for touching the area and gentle internal vaginal manual therapy for tightness and spasm of the levator ani pelvic floor muscles. Instructions focusing on relaxing the pelvic floor muscles (rather than tightening like a Kegel exercise) helped. By the 10th week of treatment (6 PT sessions), Jessica went back to pain-free intercourse and was able to urinate without straining. She also learned strategies for bowel, bladder, and sex that will help her in the future.

Case Discussion:Why did this seem to go from UTI/Yeast Infections to a problem with intercourse and urination?I will expand on this section soon - get ready for talk about viscero-somatic and somato-visceral reflexes and more! * A team approach worked well, with the GYN prescribing muscle relaxers for the patient to take at night. We could also monitor symptoms to make sure Jessica was no longer having any other recurrent infections. *This post will have more details soon! Stay tuned.